NEW PROCESS FOR APPEALING MEDICAID MCOS’ ADVERSE CLAIM DETERMINATIONS

On June 7, 2017, Louisiana House Bill 492 (HB 492) was sent to the Governor for executive approval. This Bill establishes a process for review of healthcare provider claims denied by Medicaid managed care organizations (MCOs).
HB 492 will apply to the following “adverse determinations” by Medicaid MCOs:

(1) A decision by an MCO that denies all or part of a claim;
(2) A decision by an MCO that only partially pays a claim; and
(3) A decision by a MCO that results in recoupment of payment for a claim.

Healthcare providers will have the right to request review of these adverse determinations shown on remittance advice or other written or electronic notice from an MCO. Contractual provisions between a provider and an MCO seeking to limit or impede this new appeal process will be treated as null, void and contrary to the public policy of this state.

The new appeal process will apply to claims filed on or after January 1, 2018. Any adverse determination already involved in litigation or arbitration or which is not associated with a Medicaid enrollee is not eligible for independent review. The procedure for appealing an adverse determination is as follows:

Initial Request for Reconsideration

The provider must submit a written request for reconsideration to the MCO and any supporting documentation within 180 days from:

(a) The date the MCO transmitted the remittance advice or other electronic notice, or the postmark date if the remittance advice or other notice was provided in non-electronic format; or

(b) 60 Days from the date the claim was submitted to the MCO if no remittance advice or other written or electronic notice is received from the MCO partially or totally denying the claim; or

(c) The date the MCO recoups monies paid for a previous claim.

The MCO must acknowledge receipt of the reconsideration request, in writing, within 5 calendar days after receiving it unless a longer time is agreed to in writing by the provider and the MCO.

The MCO must issue its decision within 45 calendar days from the date of receiving the request for reconsideration unless a longer time is agreed to in writing by the parties.

Independent Review of Adverse Determination

If the MCO reverses itself, it must pay the claim within 20 calendar days from the decision date. If the MCO upholds its initial claim determination or does not respond to the reconsideration request within 45 days, the provider may file a request for independent review of the adverse determination. The request must be filed with the Louisiana Department of Health (LDH) in writing within 60 days of receiving the notice of decision or, if the MCO fails to respond, on day 45 after the MCO received the provider’s reconsideration request.

Within 14 calendar days, the independent reviewer (IR) must request that the provider and the MCO submit all information and documentation regarding the disputed claim(s). The IR will not consider any information/documentation submitted more than 30 days after receipt of its request, nor any information the provider did not previously give to the MCO as part of its original request for reconsideration.

The IR may request guidance from the LDH on a medical issue. If that issue involves medical necessity, the response from LDH must come from a Louisiana licensed physician in the same specialty as that involved with the claim. LDH must provide its response to the IR within 90 calendar days of the IR’s request.

After receiving all information requested from the provider and MCO or their failure to provide same, the IR must render a decision within 60 calendar days. It may, however, request an extension of time, in writing, from LDH. If the IR’s decision is favorable to the provider, the MCO must pay the claim within 20 calendar days of the decision, with interest back to the date the claim was originally denied or recouped.

Either party dissatisfied with the IR’s decision may file suit in the parish where the provider or MCO is domiciled. “Reasonable” attorney’s fees of no more than $500 plus expenses may be recovered by the prevailing party.

Who Pays the Cost of the Independent Reviewer

Initially, the MCO must pay the fee for the independent review. If the MCO’s decision is upheld, the provider must reimburse the MCO within 10 days of the IR decision. If the provider fails to pay the fee within that time, the MCO may withhold future payments from the provider equal to the cost of the independent review fee. The MCO must, however, ensure that the withholding is clearly identified on the remittance advice. Additionally, the LDH may prohibit the provider from future participation in the independent review process for failure to pay this fee.

For assistance with navigating the new Medicaid MCO appeals process, please contact us at the address shown at the bottom of the page. To access a copy of the enrolled text of HB 492, go to: